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OR OFFICE USE: ----------------------------.____.-------------- -------- APPLICATION FOR SANITATION PERMIT r 'Permit No. ..1... .a.. --------------------------- ------------I--------------- ^ '(Complete in 'Duplicate)l - --- This Permit Ex ires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No, JOBADDRESS A LOCATION_____ ----- •- - -- -------- - ---------------- ------•---------------------------------------- Owner's Name.-- I --•- ----- Phone -- -�-------- Address-----------•------- -------- - - -- Contractor's Name--------- - --(Z---------1 —--------------------------------------- ---------------------- Phone---------------------------- ' Installation will serve: Residence [R-'?�partment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: ___ _- Number of bedrooms ____Number of baths _-/____ Lot size Water Supply: Public.system ❑ Community system -[] Private Depth to Water Table A-11,T-t- 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe fRe-Hardpan ❑ Previous Application Made: (If yes,date____________________) No P"' New Construction: Yes , -< ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: _.. (No septic tank or cesspool permitted if public sewer is avai[able within 200 feet.) Septic Tan Distance from nearest well-- -_i-_-Distance-from foundation_/D-.______._.Material_ _ r. --- -------- V11 No. of compartments _ l� p - Size--� -•------ Liquid depth 7- .-----Capacity -}� ------- Disposal Fi Id: Distance from nearest well--SP----- from founclation-,1.0_.-_f___.Distance to nearest loot line- Number of fines-_-._____ Length of each line_--.�}__.��____--.Width of french___.__-____ ______________ - - - - 1 Type'of filter material:__/a.............Deptli of filter material__--lop-------__..Total length___�4"ZJ__-__.___----__- ! ------ / $eepage Distance to nearest well._._ _�� Distance foundation__ i c+�. f __________.Distance to nearest lot line:____________ Number of pits______________________Lining material: Gr ---Size: Diameter_� __j�------Depth_' c�- ---- Cesspool: Distance from nearest well----------_------Distance from foundation-----_-------------.Lining material_____.__ _______._.__.___--_/___ ---- EJ Size: Diameter------------ -- ---------------Depth--- -------- -- ---------- - ---------------Liquid Capacity----------------------------gals . ... E ,.. . Privy: Distance from nearest well---------- ____-.__________________ Distance from"nearest building g------ ------------------- ------ ❑ Distance to nearest lot fine- ---------------------------- ------------------------------------------------ Remodeling and/or repairing (describe):_____.._..______ ----------- ----------------- -- -------------------------------•---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws and rules and regulaltions of the San Joaquin Local Health District. (Signed) ------•--------------- = !------------- 3¢r� ----- -------------------------------------------------------------- ----(Owner and/or Contractor N BY ------(Title)------ - ------- - - - (Plot plan, showing size of lot, locati of s .stem in relation to wells, ui dings, etc., can be placed on reverse si [ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED --------------------------- DATE------ '. REVIEWEDBY------ --------------------'------- ----------------- --------------------------------------- ----------------------------- DATE------------ # BUILDING PERMIT ISSUED----------------- -) ___-_ ------------------ - --------------------- -------------------- D ------Ir*-1 ------- Alterations and/or recommendations:.__ _____ ___ _ 5 � --- ---------------------------- - ----- = ---------------- ------ -----------------------...------------- ---------- -------------- - ---- ------------ ----- --- FINAL INSPECTION BY:.... ............ ------------------ Date-- - �.--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.c o. y